There is enormous variation in the care delivered to patients with chronic illnesses as documented in numerous documents from authoritative sources including the Institute of Medicine. I have become convinced that most patients are able to understand the issues involved if they are presented properly. If you have type 2 diabetes, it is important that you educate yourself so that you can be confident that you are receiving the care that you should have.

Type 2 diabetes is a vascular disease

First, type 2 diabetes is essentially a vascular disease. Virtually everything bad that happens to adult-onset diabetics is vascular, especially the most dreaded and lasting complications. Of course, stroke and heart attack are vascular. Lower limb amputation is vascular. But the blindness, nerve damage, and kidney failure are vascular also—these are microvascular complications and they are reduced by controlling sugar aggressively. The strokes, heart attacks, and amputations are related to large vessels and these problems have been much more difficult to influence.

We have not been able to show consistent reductions in large artery diabetic disease with any diabetic medication until the UKPDS study from Great Britain documented a 39% reduction in heart attack and a 42% reduction in diabetic deaths with metformin. These reductions are on the same order of magnitude as the most powerful medical treatments for vascular disease that control cholesterol and blood pressure.

These effects are well-documented in the medical literature but most who work to provide optimal medical treatment for these patients are very comfortable with pressure and sugar management, but less comfortable with diabetes management. The recent COURAGE and WISE studies discussed optimal medical care for high-risk vascular patients but made little mention of medical management of diabetes.

Key treatment considerations

Here are some key considerations on treatment. We do too little too late. The type 2 diabetic has had metabolic abnormalities that favor the development of vascular disease for two decades. These effects are so profound that at the time of diagnosis, the diabetic has the same risk of a heart attack as someone who has already had a heart attack.

At diagnosis, it is essential that aggressive medical treatment begins. At diagnosis, type 2 diabetics are relatively insulin deficient. They have lost half of their insulin-producing capacity and they are insulin resistant which is why the sugar begins to climb. A recent consensus statement from the ADA and the European Association for the study of diabetes says,

“lifestyle interventions should be initiated as the first step in treating new-onset type 2 diabetes…the authors recognize that for most individuals with type 2 diabetes, lifestyle interventions fail to achieve or maintain metabolic goals, either because of failure to lose weight, weight regain, progressive disease, or a combinations of factors. Therefore, our consensus is that metformin therapy should be initiated concurrent with lifestyle intervention at diagnosis.”

A second drug with some evidence of vascular event reduction is pioglitazone and that is a good choice when a second drug is required. Finally, failure to control sugars causes a vicious cycle of damage to the pancreas that reduces insulin production with increased glucose levels and more toxicity to the pancreas. Insulin is typically used too little and too late. Patients make the mistake of negotiating with their providers to avoid insulin therapy, and relatively reduced insulin production is a predictable fact in type 2 diabetes. Most patients need insulin sooner or later.

Metformin with a long-acting insulin that the patient adjusts themselves gives durable control of sugar levels to most patients. That regimen puts the patient in control.

Sulfonylurea drugs typically only work for a short period of time, cause more hypoglycemia, and cause weight gain. There are a number of studies that have shown increased numbers of vascular events with these medications and these effects have been explained away statistically. Their only advantage is cost and convenience.

Type 2 diabetic patients should also receive ACE inhibitors and statin drugs regardless of their pressure and cholesterol levels.

Type 2 diabetes is a very dangerous ailment, but with proper and early treatment the serious complications of this disease can be dramatically reduced.

William H. Bestermann Jr., MD is a board-certified internist who practiced preventive cardiology for 20 years. He has been heavily involved with health care reform and quality improvement during that same period. He wrote the first article on a systematic approach to the metabolic syndrome. He led an advanced cardiometabolic medical home that managed high-risk diabetic and hypertensive patients for a Fortune 100 company in Tennessee. He is a Senior Clinical Advisor for the Quality Blue Primary Care program at Blue Cross Blue Shield of Louisiana. That initiative saved $27 pmpm net at the 18 month mark while reducing hospitalizations, length of stay, and specialty referrals. He is currently the Chief Medical Officer at Epigenex Health Inc.

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